In this insightful episode, Dr. Rhiannon Winsor sits down with Dr. Andy Mayberry, a longtime family physician at Chiricahua Community Health Centers, to explore the art and science of managing high-risk patients. From chronic disease and smoking cessation to care coordination and patient follow-up, Dr. Mayberry explains how proactive communication, preventive screenings, and consistent visits can dramatically improve outcomes. He also discusses the Risk Adjustment Factor (RAF) score as a useful framework for identifying high-risk patients and designing visit schedules that catch problems early. Listeners will walk away with practical ideas for improving chronic care management, supporting patients with multiple conditions, and re-centering healthcare around prevention and human connection.

Key Topics:

• Defining and identifying high-risk patients using RAF scores
• The long-term impact of preventive care
• Coordinating care among specialists
• Empowering patients through follow-up and advocacy
• The role of chronic care management programs (CCM) in improving outcomes